Navigating Bulimia
A guide for what to expect when starting treatment for Bulimia Nervosa
Welcome back to the ‘Navigating’ Series
We’re approaching the end of the Navigating an Eating Disorder series! Once a month, I post an overview of what goes into eating disorder treatment for each of the different diagnoses under the eating disorder umbrella. I’ve enjoyed writing these and hope that you’ve found them helpful. I wanted to start this project under The Full Life because there are so many misconceptions about what it means to develop an eating disorder. This leads to people judging themselves for struggling and to friends and family not knowing how to support their loved ones because they don’t really understand what is going on. When we can break down the complicated nature of struggling with food, we can create a more compassionate culture for those who need help and support. Eating disorders are some of the few diagnoses that are as much a mental illness as they are a physical illness. There are psychological and physiological factors that influence the development of disordered patterns and the maintenance of these behaviors and symptoms over time. This makes it incredibly difficult to work through the recovery process without a significant amount of support. When working toward recovery, a person is unlearning unhelpful beliefs, challenging themselves to think more flexibly, dealing with uncomfortable gastrointestinal side effects, eating even when their body and brain are telling them not to, and eating things that may make them feel nervous. Going through eating disorder treatment is uncomfortable, sometimes painful, and incredibly challenging. I also believe that it is entirely worth it to get to a place of confidence and trust that eating food is a good and necessary part of being a human.
If you have any questions or additional considerations, please feel free to leave a comment!
Etiology
When we discuss any eating disorder, and bulimia is no different, I want to note that there are more similarities than differences between each disorder - particularly in regard to how they manifest. And, as always, there is oftentimes a component of restriction in the overall behavior picture. What I typically see is that restriction was the first symptom of the eating disorder - for whatever reason the individual might have. Culturally, we celebrate restriction. Being on a diet, “taking control of your health”, or attempting weight loss are all ways that we might assimilate into diet culture and increase our acceptability.
As we discussed in Navigating Anorexia, it is not biologically beneficial for human beings to be great at restricting. Humans need food to survive, so, for most of us, there comes a point of “override” when our bodies will seek out food and in quantities that may feel uncomfortable. Particularly for someone who is intentionally restricting their energy intake. When this happens, people tend to report feeling out of control. They might note that it feels like they couldn’t stop eating even if they wanted to and that they tend to eat foods that are usually restricted - although any food is fair game. More often than not, there is guilt and shame present around the behavior. Some people feel uncomfortable and unable to cope with the experience of overeating and move to purging behaviors, but those who don’t might meet the criteria for Binge Eating Disorder.
Purging broadly refers to any form of compensation after eating. Many of us think of intentional vomiting, but people can also compensate with exercise, restriction, or medications. These compensatory behaviors might alleviate some of the negative emotions that one feels after bingeing, but they can also add fuel to this cycle. Purging can serve to “restart” the restrictive behaviors, empty the system, and get “back on track”. From there, we enter a seemingly endless cycle of avoiding food, finally eating food, potentially eating more food than we are comfortable with, and compensating for the food eaten. It takes a significant toll on the body and is most often hidden from friends and family due to the tremendous amount of inner turmoil that individuals associate with these behaviors. There can be a feeling that we just need more self-control or that we are addicted to the foods that we gravitate toward when bingeing.
We normalize this cycle all the time. Cheat meals, “saving up calories”, post meal “burns”, etc., etc., etc. all are ways that people compensate for eating all the time. The dieting process isn’t sustainable for many, so lots of us are operating within a subclinical eating disorder off and on throughout their life. This is the reason that, at least for females, those who diet are between 5x and 18x more likely to develop an eating disorder.
While the experience I described above is a common one, I have also met with clients who struggle with these behaviors as a form of self-harm, who use these behaviors during periods of depression or mental illness as a way to feel a different emotion, to reduce their overall sensation of numbness, or who punish themselves for unrelated experiences or beliefs about themselves. I always recommend having a therapist on the team, but if these are the root cause of the eating disorder behaviors, it is vital to include a therapist as part of the treatment team.
Behaviors, signs, symptoms
Let’s jump in and take a look at the DSM diagnostic criteria for diagnosing Bulimia:
Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
Eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating).
Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.
The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for three months.
Self-evaluation is unduly influenced by body shape and weight.
The disturbance does not occur exclusively during episodes of anorexia nervosa (as in the symptomology doesn’t meet criteria for anorexia - then we would diagnose these behaviors as Anorexia - binge/purge subtype).
The diagnostic criteria are, once again, incredibly narrow. Meeting the diagnosis of bulimia can be tricky as behaviors can evolve over time, sometimes being more restrictive, sometimes having more frequent b/p (binge/purge) behaviors, and sometimes experiencing a more “normal” relationship with food. In the next iteration of the Navigating series, we’ll talk about all of those who are struggling with an eating disorder without perfectly matching the diagnosis of AN/BN/BED/ARFID.
Since compensation is a key marker of the presence of bulimia on comparison to anorexia or binge eating disorder, we can start with the symptoms or signals that the way we are “making up” for eating are harming us.
In the case of exercise, we might start to see some of the signs of RED-S. Typically seen in athletes, RED-S stands for relative energy deficiency in sport, but we used to call this diagnosis the Female Athlete Triad. When we are expending significantly more energy than we are taking in, it can negatively impact our hormone balance, our ability to have a period, having a high enough fat mass to support our body, our energy levels, our risk of bone injury, and our bone density. Frequently being injured from exercise is not a benign symptom and investigating nutritional adequacy in the diet is one of the first things we should look to.
The medications listed above can all be abused in an attempt to rid the body of nutrition after eating or to attempt to reduce body size. Laxative abuse can impact the functionality of our intestines over time and potentially reduce our ability to have normal bowel movements without the aid of medication. Diet pills are unregulated by the FDA and commonly include dangerous ingredients that can cause significant harm, interact with other vitamins or medications, and are rarely even effective at what they claim to do.
Intentional vomiting after meals puts our electrolyte balance at risk which is particularly concerning for our heart function as well as general wellbeing. We can also permanently damage our esophagus over time, increasing our risk of cancer and difficulty swallowing. Long term vomiting after meals can also cause acid reflux and heartburn, tooth decay, and delayed gastric emptying.
There is no “safe” form of purging or compensation, and anyone who is finding it difficult to tolerate eating food regularly should seek support.
Treatment
There are three major symptom patterns that are present with bulimia: restricting/food avoidance/food guilt/body dissatisfaction (any one or combination of these), bingeing, and purging. I find that treating each symptom as it’s own “thing” is useful in making treatment feel more manageable.
If restriction of energy or nutrients is present, we start there. This is for the same reasons discussed in our navigating BED post: restriction is fueling the need to binge. This requires some nutrition education and counseling to unlearn unhelpful nutrition beliefs and learn basic nutrition facts, physiology, and nutrient needs as a human. We may work with a meal plan and build some structure for eating so the pendulum can ease from swinging widely from restriction to bingeing and back again. We are working to build up the internal systems to be able to communicate hunger, fullness, and desires while also helping the individual learn about what feels best when nourishing themself and how to loosely create a schedule and routine for eating that actually works for them.
Next, we jump ahead a bit and work on reducing purging behaviors. We do this because it is dangerous to the body and causing direct harm each time we engage in a version of purging and also because the B/P process becomes significantly less satisfying to the eating disorder if we can keep ourselves from purging after a binge. Interrupting the transition from bingeing to purging is the first step. We can start by setting a timer, counting to 10, leaving the room before coming back, or really anything that will help counteract the automatic shift from bingeing into compensation. This helps a person to feel a bit more in control, more self-aware, and may help them to experience a bit of what is going on in their brain and their body. It is common for someone who is using these behaviors to feel a bit dissociated or checked out while the B/P plays out, so if we can wiggle in there to create a little moment of presence it can start a bit of a rift for us to work through together.
We don’t need to see complete resolution of restriction before moving to purging or for purging before we start to target the bingeing. But we want to start the process in these two places and feel some increased awareness prior to moving to bingeing. Now, we want to build on internal sensations of emotions, feelings, hunger, fullness, and everything in between. We start to treat the body as a friend rather than an enemy - listening, not judging, caretaking, and showing compassion. We look for experiences that trigger urges for a binge. There are about a million reasons that a person might get bingeing urges, but some examples could be feeling extremely hungry, seeing a picture of ourselves that makes us uncomfortable, getting in an argument, dieting thoughts, or having a bad day. Getting to know the why behind the bingeing can be extremely helpful - what emotions does the binge counteract and/or what emotions does the binge help you to feel? Using a journal or other method of introspection can get us into the headspace to explore this in our own mind and to take those thougths to therapy or nutrition sessions to explore further. Knowing triggers or emotional experiences that lead to urges isn’t the end of the story. Once we are aware of these triggers we can start to target specific skills, coping strategies, therapeutic modalities, or connection opportunities to help us fill those gaps and meet our human needs without relying on the eating disorder. Treatment takes time and we don’t typically see quick resolution of symptoms. We may also see a bit of “whack-a-mole” going on - reduction in any one behavior can spark a need for more intense coping and we can see people gravitate to different behaviors as they learn to use more helpful coping tactics.
Goals for Recovery
We always want to prioritize the client’s goals for themself - what does life look like for them in recovery? How do they want to feel? How do they want to take care of themselves? From there we can work toward that experience and also include some baseline goals such as improvement in health, decrease in stress/overwhelm, increased use of skills and support, and feeling as though they don’t need to use eating disorder behaviors. For many with a bingeing and purging behavior subset, these experiences cause shame and guilt - there is usually strong motivation to not engage with these behaviors, but difficulty in making the change as they provide so much intangible support to one’s emotional experience and can meet their biological needs if they are simultaneously restricting.
So, what are the major signs that we have successfully treated Bulimia?
Normalization of food intake - eating 4-6 times per day, regularly eating all food groups, and meeting energy needs.
Reduction or complete remission of bingeing and purging behaviors and the ability to navigate difficult experiences and emotions without turning to these behaviors to cope.
Normalization of any previously abnormal labs or nutritional deficiencies
Reduction and/or treatment of any side effects like GERD/heartburn, delayed gastric emptying or other GI dysfunction, tooth care, etc.
An improvement in body image, self-confidence, self-compassion, and an overall improvement in feeling of self-worth.
Identification of triggers for behaviors and a plan to navigate these triggers when they arise.
If you have bulimia or are the caregiver to someone with an eating disorder, I hope this guide helps you in tailoring your treatment to your own needs and desires. I also hope it helps you in seeking out a professional to support you on your journey - ask questions and make sure the provider’s approaches are in line with your goals and needs. This is just an introduction to the basics of understanding and treating a complex mental and physical disorder. If you have more questions or want more information, please feel free to reach out via the comments or DM me.